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Do steroids scare you? Have you heard steroids are “bad?” If so, you may be mistaking
commonly prescribed corticosteroids for anabolic steroids. While both have benefits and side
effects, anabolic steroids are widely abused and can cause serious health problems. In fact,
their notorious reputation is part of the reason many patients who can benefit from
corticosteroids often try to steer clear of them.
Anabolic vs. corticosteroids
Anabolic steroids are man-made drugs that mimic
the male sex hormone testosterone. Like testosterone, they can build muscle and increase
the presence of masculine characteristics. Anabolic steroids are sometimes prescribed for
patients who make too little testosterone, can be life-saving for individuals with
hereditary angioedema (a swelling disorder), and are very useful in treating diseases
that cause muscle wasting, such as AIDS.
Anabolic steroids are commonly used illegally by athletes and bodybuilders hoping to
increase body size and optimize performance. The physical and emotional side effects
associated with such abuse can be devastating. Anabolic steroid abuse can increase the
risk of stroke, heart attack, liver cancer, severe acne and a host of other medical
problems. The drugs are well known for causing violent behavior, wild mood swings, paranoia
and depression. Stories about these side effects make for great headline news, but they also
give all steroids a bad name and scare the public.
Despite sharing the word “steroid,” anabolic steroids and corticosteroids have little in common. Corticosteroids are manmade (or “synthetic”) drugs designed to produce the same effects as cortisol, a steroid hormone produced by the adrenal glands, which rest on top of the kidneys. Cortisol produced by the body exerts its action in many ways, helping to maintain various bodily functions. At higher than normal levels, cortisol—or corticosteroids—can inhibit inflammation and depress the immune system.
More than 100 corticosteroids have been approved by the Food and Drug Administration (FDA). Some corticosteroids can help prevent the nausea and vomiting associated with chemotherapy. Others are used as immunosuppressants to help prevent the immune system from rejecting transplanted organs. Addison’s disease, a condition in which cortisol production falls below normal levels, is treated with corticosteroid therapy. In most cases, however, corticosteroids are prescribed when the body needs more cortisol to fight an inflammatory disease or condition, for example rheumatoid arthritis, asthma, severe allergies or inflammatory bowel disease.
In general, corticosteroids are well tolerated. But they also are more potent than naturally produced cortisol. Thus, corticosteroid therapy may be associated with side effects, so they should be carefully prescribed.
Corticosteroids can be given orally, intramuscularly, intravenously or intranasally; they also can be inhaled. They may be prescribed for short-term therapy, or patients may need to remain on steroids for years. Each form of delivery and the length of treatment is associated with a specific risk. Short-term corticosteroid use may be associated with weight gain, stomach upset and mood swings. These side effects are temporary and stop when the medication is discontinued.
Long-term use of inhaled or oral corticosteroids can have health and medical consequences. Steroids interfere with collagen formation, making skin thin and fragile. Blood vessels also may be affected, causing patients to bruise easily. The longer corticosteroids are used, or the higher the doses, the greater these effects.
Because corticosteroids interrupt calcium/phosphate metabolism, the risk for osteoporosis increases. People already at increased risk, particularly white women of northern European origin and any woman with a family history of osteoporosis, require regular bone density testing. These patients should also take vitamin D and calcium supplements to help safeguard against bone loss.
Long-term use of oral or intramuscular steroids may be associated with the development of cataracts and glaucoma, so regular eye examinations are needed.
Steroids for asthma
One of the most common uses for corticosteroids is in the treatment of asthma. The majority of asthma patients use inhaled corticosteroids to reduce the inflammation in their lungs that prevent them from getting enough air. With so many patients wary of taking steroids, asthma specialists like The Cleveland Clinic’s David M. Lang, M.D. spend a lot of time educating patients about the pros and cons of corticosteroid use.
“The risk of giving any medication like a corticosteroid should be exceeded by the risk of withholding it,” says Dr. Lang, who heads the allergy and immunology section of the Cleveland Clinic’s department of pulmonary, allergy and critical care medicine. “The risk of not using steroids is the inability to breathe. And poorly controlled asthma can be fatal.”
Even a patient who does not have severe asthma can suffer a serious flare, says Dr. Lang. “There are very few options outside of corticosteroids for treating asthma flares, and withholding the medication for a flare may be life threatening.” He says that more and more data indicate that untreated or undertreated asthma can lead to compromised lung function over time. “Although this remains controversial, treating persistent asthma appropriately—and inhaled corticosteroids are the first choice of therapy—appears to prevent or delay these undesirable changes from taking place.”
While the patient education process continues, pharmaceutical companies are scrambling to find nonsteroidal alternatives that can be used to treat many diseases. “Steroid sparing” drugs for asthma and allergic rhinitis now include a special agent (Xolair) to act against IgE (immunoglobulin E), a class of antibodies produced in the lungs, skin, and mucous membranes and that control the allergic response underlying asthma. An anti-IgE drug could knock out the allergic reaction before it starts. Another class of drugs is designed to stop the action of leukotrienes, which are released during the allergic inflammatory process. While these new drugs offer benefits for some patients, Dr. Lang says that the current evidence continues to support use of inhaled corticosteroids as the most favorable therapeutic option for long-term management of asthma.
“I encourage physicians to have open discussions with their asthmatic patients about the risks and benefits of corticosteroid use and to ask them about their concerns. Some concerns can be easily resolved. Others may be unfounded,” he says.
But he also says it is up to patients to raise any concerns they may have when a corticosteroid is prescribed, and to carefully follow the dosing instructions for the drugs. “When steroids are used correctly,” says Dr. Lang, “they can help millions of people control their disease and improve their quality of life.”
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